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.', •V' Y APPLICATION FOR PERMIT SAN jOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONIMTAL HEALTH DIVISION , 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 p T EBPIRES Y FR Il D T SUED (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the Rulevorks herein Regdesulations of Sans application is made in compliance with San Joaquin Count Ordinance No. 5k9 and 1662 and the Rules and Ret?u1a Joaquin county Public Health Services. StvGI t Size/Acreage City Job Address ,,� S 4 CJ2 0,7 //O C� / /Q � S •®iJGE Phone rasa Owner's Name s 0.^ �/0 �' icense No. Phone -V-3-00L s Contractor klk6lressI " NEW WELL WELL REPLACEMENT L] DESTRUCTION ❑ Out of Service Hell ❑ i TYPE OF WELL/PUMP: OTHER O /'14onitoring Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. - FOUNDATION AGRICULTURE WELL OTHER WELT. PITS/SUMPS _ I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ir-tf 0 industrial ❑ Open Bottom © MantecaDia. of Well Excavation Dia. of WeH Casing Type of Casing_ Specifications Cl DomasticlPrivate ❑ Gravel Pack ❑ Tracy r Type of Grout a Cl Other C1 Delta Depth of Grout Seal ["1 Public I I irrigation M Approx. Depth I I Eastern Surface Soul Installed by H.P. State YV rk gone .Svc Repair Work Done v Type of Pump Sealing Material 4 Depth ��" Z levo .5 X4.017 y Well Destruction O Waft Diameter ��-- +CPQ-hiller Naterie.l i Depth \\ 1 Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIRIADDITION 1 I DESTRUCTION I I INavailable s tis system shin 200 feet.) it public sewer is Installation will serve: Residence— Commercial Other- Number of living units: Number of bedrooms CJI Water table depth Character of soil to a depth of 3 feet: No. Compartments w SEPTIC TANK. © Type/Mfg Capscity��— w Method of Disposal "D PKG. TREATMENT PLT.❑ Property Lina ( Distance to nearest: Well Foundation Z� LEACHING LINE ❑ No. f1 Total length!size Length of lines Pro line FILTER BED O Distance to nearest: Well Foundation perry SEEPAGE PITS 11 Depth _ Site Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Homo owner or licensed agent's signature certifies the following; "k certify that in the performance of the work for which this permit is issued, I aha I not to workman's compensation laws of California.' Contractor's hiring or sub-contracting signature Hopley any parson in such manner as to become subject 1111 r which this permit is isiuild;I shell employ parsons subject to workman's companss ceRifies the following; "I certify that in the performencs of the work fo tion laws of Cslkfanis." , The applicant must coil for all required 'ins tions. Co owing on reverse sideF r Title: Date: ` • 00, Signed .. �J9. Q O FOR DEPARTMENT USE ONLY . L Z Date Area Application Accepted by� Data Final Final inspection by Date' ' Pit or Grout inspection by �R5 1 -2P MW j Additional Comments: 4L lac D 5t & Endo c! L LSJ Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services i 445 N San Joaquin, P 0 Box 2009-, Stkn, CA 95201 CK RECEIVED Sy DATE PERMIT N0. FEE AMOUNT DUE AMOUNT REMITTE4 CASH INFO � F.� $q•Ua " T-[ i►' \ ✓�I�` [L lire [ • EN 1r44IREV.�/K 51 . EN 14.7a